Commentary on “Better Prognosis of Senile Patients with Intertrochanteric Femoral Fracture by Treatment with Open Reduction Internal Fixation than by Hip Arthroplasty”

Keywords::

• intertrochanteric femoral fracture
• internal fixation
• arthroplasty
• the elderly
• hip
• mortality

This article refers to:

Better Prognosis of Senile Patients with Intertrochanteric Femoral Fracture by Treatment with Open Reduction Internal Fixation than by Hip Arthroplasty

Intertrochanteric femoral fractures (IFFs), accounting for half number of hip fractures, are frequent and severe injuries in the senile population [1]. Different from femoral neck fractures in the elderly, intertrochanteric femoral fractures always present in much older patients and have more complicate fracture fashions as well as choice of treatment [2]. The variety of fracture care methods reflects the controversy and uncertainty of the management of IFFs. Nevertheless, the evolving concepts of osteosynthesis and geriatric orthopedics have been promoting the prognosis, and functional recovery can be achieved for the majority of fractured elderly [3]. The care of IFFs should be patient-centered, but not fracture-centered, through comprehensive evaluation of potential risks and swift establishment of treatment protocol simultaneously. By means of fracture fixation or hip arthroplasty, fractured patients had better to leave bed and regain ambulation as early as possible [4].

Author and colleagues [5] compared the prognosis of IFFs treated by open reduction internal fixation to hip arthroplasty, and found clinical outcome was better when the fractured hip was stabilized by dynamic hip screw (DHS). During the mean follow-up of 46.9 months, 31 patients died (28.2%). In terms of 1- and 2-year mortality, the priority of internal fixation was significant.

Due to severe osteoporosis, premature loading, frailty and concomitant diseases, complications following internal fixation of IFFs, including coxa vara, implant breakage and nonunion, cutting-out, traumatic osteoarthritis and osteonecrosis, are commonly seen [6]. Even with anatomic reduction and rigid stabilization, immediately leaving bed and partially loading are not recommended. Additionally, some patients have degenerative hip diseases before intertrochanteric fractures. Therefore, hip arthroplasty emerges at the right moment to conquer the deficiency of internal fixation [7]. Can early loading and free ambulation exercise be achieved following hip arthroplasty due to intertrochanteric fractures?

QUITE DIFFICULT!

Greater and (or) lesser trochanter are not intact in intertrochanteric fractures. The fractured trochanter has to be stabilized properly (usually by cerclage) during hip arthroplasty, and fracture healing is of significant importance. Meanwhile, muscular insertion to the broken trochanter determines significant complains of pain and weakness in the early period. It also has to be noted that these intertrochanteric fractures are presented in very old patients, who are always frail, sarcopenic, ataxic and of hypopsia, which in combination result in disability of early ambulation. In comparison with internal fixation, hip arthroplasty due to intertrochanteric fractures might possess longer operation time and more blood loss, which can worsen the already grave situation. Moreover, there is no specially-designed prosthesis for the treatment of intertrochanteric fractures, and best hip prosthesis to date has inherent imperfection. Postoperative complications, including dislocation, periprosthetic fractures and infection are more commonly seen than in scenario of intertrochanteric fractures treated by internal fixation or osteoarthritis by hip arthroplasty. A recent investigation revealed even for failed internal fixation of intertrochanteric fractures, salvage hip arthroplasty could result in equivalent functional outcome. Therefore, arthroplasty might be preserved as a salvage protocol for managing complications [8]. When arthroplasty is the primary treatment of choice for IFFs, the indication should be strict. Perhaps arthroplasty should become a magic sword, which should be controlled so it does not cause more injuries than it prevents, to reduce high mortality of IFFs.

For intertrochanteric fractures in the senile patients, the concept of “the final operation” should be reinforced among orthopedic surgeons, who should reduce iatrogenic risks and improve operation quality [9].

Probably, internal fixation will act as the treatment of mainstay for intertrochanteric fractures in the coming future. High mortality is closely associated with the fracture itself [10], and surgeons cannot alter any objective factors, such as advanced age, systemic comorbidity and fracture fashion. However, we can struggle to take more active treatment mode to reduce injury-to-surgery interval, improve operation quality, provide comprehensive therapy and prevent early lethal complications such as pneumonia and cerebrovascular accidents. As our patients' age and their expectation grow, the treatment of intertrochanteric fractures will become more challenging.

Declaration of interest: The authors reports no conflict of interest. The author alone is responsible for the content and writing of the article.